Provider Demographics
NPI:1447357397
Name:LANHAM, TIMOTHY STEWART (LICSW)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:STEWART
Last Name:LANHAM
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 RAWSON RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-2040
Mailing Address - Country:US
Mailing Address - Phone:617-773-5166
Mailing Address - Fax:
Practice Address - Street 1:22 SPEAR ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4514
Practice Address - Country:US
Practice Address - Phone:617-472-5428
Practice Address - Fax:617-472-4450
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1049971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO3206OtherBLUE CROSS BLUE SHIELD
MA256171OtherMAGELLAN
MAPO3206Medicare ID - Type Unspecified